AUA Guideline Urotrauma PDF

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J Urol. Author manuscript; available in PMC 2014 August 01.
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J Urol. 2014 August ; 192(2): 327–335. doi:10.1016/j.juro.2014.05.004.
UROTRAUMA: AUA GUIDELINE

Allen F. Morey, MD, Steve Brandes, MD, Daniel David Dugi III, MD, John H. Armstrong, MD,
Benjamin N. Breyer, MD, Joshua A. Broghammer, MD, Bradley A. Erickson, MD, Jeff
Holzbeierlein, MD, Steven J. Hudak, MD, Stuart Mirvis, MD, Jeffrey H. Pruitt, MD, James T.
Reston, PhD, MPH, Richard A. Santucci, MD, Thomas G. Smith III, MD, and Hunter
Wessells, MD
Abstract
Purpose—The authors of this guideline reviewed the urologic trauma literature to guide
clinicians in the appropriate methods of evaluation and management of genitourinary injuries.
Methods—A systematic review of the literature using the MEDLINE® and EMBASE databases
(search dates 1/1/90-9/19/12) was conducted to identify peer-reviewed publications relevant to
urotrauma. The review yielded an evidence base of 372 studies after application of inclusion/
exclusion criteria. These publications were used to inform the statements presented in the
guideline as Standards, Recommendations or Options. When sufficient evidence existed, the body
of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or
C (low). In the absence of sufficient evidence, additional information is provided as Clinical
Principles and Expert Opinions.
Copyright © 2014 American Urological Association Education and Research, Inc.®

Urotrauma Panel, Consultants and Staff Panel Allen F. Morey, MD (Chair) UT Southwestern Medical Center Dallas, TX
Steve Brandes, MD (Vice Chair) Washington University Medical Center Saint Louis, MO
John H. Armstrong, MD, FACS USF Health Simulation Center Tampa, FL
Benjamin N. Breyer, MD University of California, San Francisco San Francisco, CA
Joshua A. Broghammer, MD University of Kansas Medical Center Kansas City, KS
Daniel David Dugi III, MD Oregon Health and Science University Portland OR
Bradley A. Erickson, MD University of Iowa Hospitals and Clinics Iowa City, IA
Jeff Holzbeierlein, MD (PGC Rep) Kansas University Medical Center Kansas City, KS
Steven J. Hudak, MD UT Southwestern Medical Center Dallas, TX
Jeffrey H. Pruitt, MD UT Southwestern Medical Center Dallas, TX
Richard A. Santucci, MD Detroit Medical Center Detroit, MI
Thomas G. Smith III, MD Baylor College of Medicine Houston, TX
Hunter Wessells, MD Harborview Medical Center Seattle, WA
Consultant James T. Reston, PhD, MPH James Robert White, PhD
Staff Heddy Hubbard, PhD., MPH, RN, FAAN Michael Folmer Abid Khan, MHS Carla Foster, MPH Erin Kirkby, MS Patricia
Lapera, MPH Del’Rhea Godwin-Brent
CONFLICT OF INTEREST DISCLOSURES All panel members completed COI disclosures. Relationships that have expired
(more than one year old) since the panel’s initial meeting, are listed. Those marked with (C) indicate that compensation was received;
relationships designated by (U) indicate no compensation was received.
Consultant or Advisor: Jeffrey M. Holzbeierlein: Janssen (C); Allen F. Morey, MD: American Medical Systems (C)
Meeting Participant or Lecturer: Steven B. Brandes, MD: American Medical Systems (C), Astellas (C); Jeffrey M.
Holzbeierlein, MD: Janssen (C), Amgen (C); Allen F. Morey, MD: American Medical Systems (C), Glaxo Smith Kline (C),
Coloplast (C), Pfizer (C) (Expired); Hunter Wessells, MD: National Institutes of Health
Scientific Study or Trial: Steven Benjamin Brandes, MD: Allergan (U); Joshua A. Broghammer, MD: Trauma Urologic
Reconstructive Network (U), Hunter Wessells, MD: National Institutes of Health (U)
Other: Joshua A. Broghammer, MD: American Medical Systems (C); Hunter Wessells, MD: National Institutes of Health (U)
Morey et al. Page 2
INTRODUCTION
Purpose
Urologic injury often occurs in the context of severe multisystem trauma that requires close
cooperation with trauma surgeons. The urologist remains an important consultant to the
trauma team, helping to ensure that the radiographic evaluation of urogenital structures is
performed efficiently and accurately, and that the function of the genitourinary system is
preserved whenever possible. Immediate interventions for acute urologic injuries often
require flexibility in accordance with damage control principles in critically ill patients. In
treating urotrauma patients, urologists must be familiar with both open surgical techniques
and minimally invasive techniques for achieving hemostasis and/or urinary drainage. The
Panel’s purpose is to review the existing literature pertaining to the acute care of urologic
injuries in an effort to develop effective guidelines for appropriate diagnosis and
intervention strategies in the setting of urotrauma.
Methodology
A comprehensive search of the literature targeted the five main urotrauma topics within the
scope of this guideline. The search used an extensive list of keywords related to renal,
ureteral, bladder, urethral, and genital trauma. A full list of keywords and the search strategy
are available on request. This search covered articles published between January 1990 and
September 2012. Study designs consisting of randomized controlled trials (RCTs),
controlled clinical trials (CCTs), and observational studies (diagnostic accuracy studies,
cohort with and without comparison group, case-control, case series) were included.
Systematic reviews were included if they performed a quantitative analysis of data that did
not overlap with data from other included studies; otherwise they were retrieved only for
hand-searches of their bibliographies.
The following publications and study types were excluded: preclinical studies (e.g., animal
models), meeting abstracts, commentary, editorials, non-English language studies, pediatric
studies (except for specific key questions associated with renal trauma, ureteropelvic
junction [UPJ] trauma and bladder neck/ urethral trauma), and studies of urethral and genital
injuries that did not separately analyze data from males and females. Studies with less than
10 patients were excluded from further evaluation and thus data extraction given the
unreliability of the statistical estimates and conclusions that could be derived from them.
The review yielded an evidence base of 372 studies after application of inclusion/exclusion
criteria.
Quality of Studies and Determination of Evidence Strength—Quality of

individual studies was rated as high, moderate, or low based on instruments tailored to
specific study designs. RCTs were assessed using the Cochrane Risk of Bias tool.1
Conventional diagnostic cohort studies, diagnostic case-control studies, or diagnostic case
series that presented data on diagnostic test characteristics were assessed using the
QUADAS-2 tool2 that evaluates the quality of diagnostic accuracy studies. Cohort studies
with a comparison of interest were evaluated with the Drug Effectiveness Review Project
instrument.3 There is no widely agreed upon quality assessment tool for case series that do

Morey et al. Page 3
not present data on diagnostic test characteristics, thus the quality of individual case series
was not formally assessed with an instrument. Instead, these studies were labeled as low
quality due to their study design.
The categorization of evidence strength is conceptually distinct from the quality of

individual studies. Evidence strength refers to the body of evidence available for a particular
question and includes consideration of study design, individual study quality, consistency of
findings across studies, adequacy of sample sizes, and generalizability of samples, settings,
and treatments for the purposes of the guideline. The AUA categorizes body of evidence
strength as Grade A (well-conducted RCTs or exceptionally strong observational studies),
Grade B (RCTs with some weaknesses of procedure or generalizability or generally strong
observational studies), or Grade C (observational studies that are inconsistent, have small
sample sizes, or have other problems that potentially confound interpretation of data).
Because most of the available evidence consisted of low quality case series, the majority of
evidence was considered Grade C.
AUA Nomenclature: Linking Statement Type to Evidence Strength—The AUA

nomenclature system explicitly links statement type to body of evidence strength and the
Panel’s judgment regarding the balance between benefits and risks/burdens.4Standards are
directive statements that an action should (benefits outweigh risks/burdens) or should not
(risks/burdens outweigh benefits) be undertaken based on Grade A or Grade B evidence.
Recommendations are directive statements that an action should (benefits outweigh risks/
burdens) or should not (risks/burdens outweigh benefits) be undertaken based on Grade C
evidence. Options are non-directive statements that leave the decision to take an action up to
the individual clinician and patient because the balance between benefits and risks/burdens
appears relatively equal or appears unclear; the decision is based on full consideration of the
patient’s prior clinical history, current quality of life, preferences and values. Options may
be supported by Grade A, B, or C evidence.
In some instances, the review revealed insufficient publications to address certain questions
from an evidence basis; therefore, some statements are provided as Clinical Principles or
Expert Opinions with consensus achieved using a modified Delphi technique if differences
of opinion emerged.5 A Clinical Principle is a statement about a component of clinical care
that is widely agreed upon by urologists or other clinicians for which there may or may not
be evidence in the medical literature. Expert Opinion refers to a statement, achieved by

consensus of the Panel, that is based on members’ clinical training, experience, knowledge,
and judgment for which there is no evidence.
Limitations of the Literature—The Panel proceeded with full awareness of the

limitations of the urotrauma literature. These limitations include heterogeneous patient
groups, small sample sizes, lack of studies with diagnostic accuracy data, lack of RCTs or
controlled studies with patient outcome data, and use of a variety of outcome measures.
Overall, these difficulties precluded use of meta-analytic procedures or other quantitative
analyses. Instead, narrative syntheses were used to summarize the evidence for the questions
of interest.

Morey et al. Page 4
Panel Selection and Peer Review Process—The Panel was created by the American
Urological Association Education and Research, Inc. (AUA). The Practice Guidelines
Committee (PGC) of the AUA selected the Panel Chair and Vice Chair who in turn
appointed the additional panel members, all of whom have specific expertise with regard to
the guideline subject. Once nominated, panel members are asked to record their conflict of
interest (COI) statements, providing specific details on the AUA interactive web site. These
details are first reviewed by the Guidelines Oversight Committee (GOC), a member sub-
committee from the PGC consisting of the Vice Chair of the PGC and two other members.
The GOC determines whether the individual has potential conflicts related to the guideline.
If there are no conflicts, then the nominee’s COI is reviewed and approved by the AUA
Judicial and Ethics (J&E) committee. A majority of panel members may not have
relationships relevant to the guideline topic.
The AUA conducted an extensive peer review process. The initial draft of this Guideline
was distributed to 69 peer reviewers of varying backgrounds; 35 responded with comments.
The panel reviewed and discussed all submitted comments and revised the draft as needed.
Once finalized, the Guideline was submitted for approval to the PGC. It was then submitted
to the AUA Board of Directors for final approval. Funding of the panel was provided by the
AUA. Panel members received no remuneration for their work.
Background & Epidemiology

Trauma refers to injury caused by external force from a variety of mechanisms, including
traffic- or transportation-related injuries, falls, assault (e.g., blunt weapon, stabbing,
gunshot), explosions, etc. Injuries are frequently referred to as being either blunt or
penetrating injuries as these different basic mechanisms have implications for management
and outcomes. Blast injuries may have features of both penetrating and blunt trauma, and are
most common in settings of war or violent conflict.
Traumatic injuries are the leading cause of death in the United States for people ages 1-44
years, and a significant cause of morbidity and loss of productive life across all ages.6
Worldwide, traumatic injuries are the sixth leading cause of death and the fifth leading cause
of moderate and severe disability.7 Young males ages 15-24 have the greatest burden of
injury.8 Isolated urologic injuries are uncommon in major trauma as the kidneys, ureters,
and bladder are well protected within the abdomen and pelvis, and the penis and testes are
physically mobile. Urologic injuries are more common in the multiply-injured patient, and
urologic organs are involved in approximately 10% of abdominal traumas.9
Renal Injuries—The kidneys are the most commonly injured genitourinary organ. Civilian
renal injury occurs in up to 5% of trauma victims,10,11 and accounts for 24% of traumatic
abdominal solid organ injuries.12 The kidney is particularly vulnerable to deceleration
injuries (e.g., falls, motor vehicle collisions) because it is fixed in space only by the renal
pelvis and the vascular pedicle. Flank ecchymosis and broken ribs are signs suggestive of
renal injury. Computed tomography (CT) scan with intravenous (IV) contrast enhancement
including delayed imaging remains the most common method of evaluating for
extravasation of urine from the collecting system.

Morey et al. Page 5
Over the past few decades, management of traumatic renal injuries has changed from
operative exploration to non-operative management in the vast majority of cases. Much of
the impetus for this change comes from the recognition that, in many cases, urgent surgical
exploration of renal injuries leads to nephrectomy for the injured kidney.11 Percutaneous
angioembolization is increasingly accepted for treating ongoing bleeding without surgical
exploration.13,14 While non-operative management of the vast majority of blunt renal
injuries is now firmly established, non-operative management of penetrating and high-grade
renal injuries continues to inspire debate.15
Ureteral Injuries—Ureteral injuries are rare, accounting for 1% of urologic injuries.

Distinct from other urologic organs, ureteral injuries tend to be iatrogenic, occurring during
gynecologic, urologic, or colorectal surgery.16 The majority of ureteral injuries originating
outside of the operating room are a result of penetrating trauma. Injuries may not be
recognized early unless they are specifically investigated. Treatment may include placement
of a ureteral stent or surgical repair, depending on the severity and location of injury.
Bladder Injuries—Bladder injuries occur in approximately 1.6% of blunt abdominal

trauma victims.17 Because the bladder is well protected within the pelvis, the vast majority
of injuries are associated with pelvic fractures. The bladder rupture can occur into the
peritoneal cavity (intraperitoneal bladder rupture) or outside the peritoneal cavity
(extraperitoneal rupture). Bladder injuries are extraperitoneal in approximately 60%,
intraperitoneal in approximately 30%, and the remaining injuries are both intraperitoneal
and extraperitoneal ruptures.18 Gross hematuria is the most common sign, present in
77-100% of injuries.19 Retrograde cystography (CT or conventional) is critical as it can
determine the presence of an injury and whether it is intraperitoneal or extraperitoneal. Since
the 1980s, clinicians manage most extraperitoneal bladder ruptures non-operatively with
catheter drainage, while intraperitoneal ruptures are surgically repaired.17
Urethral Injuries—Injuries to the male urethra are divided into injuries to the posterior
urethra (at or above the membranous urethra) or anterior urethra (penile or bulbar urethra).
Posterior urethral injuries are almost exclusively associated with pelvic fractures and occur
between 1.5 and 10% of pelvic fractures; concomitant bladder injuries are present in 15% of
such urethral injuries.18,20 Urethral injuries may be partial or complete disruption of the
urethra. Anterior urethral injures may be blunt (e.g., straddle injuries, where the urethra is
crushed between the pubic bones and a fixed object) or penetrating, and the urethra may be
lacerated, crushed, or disrupted. Blood at the urethral meatus is the most common finding,
although highly variable, present in 37-93%.21 Other clinical findings include inability to
urinate, perineal/genital ecchymosis, and/or a high-riding prostate on physical exam.
Diagnosis is made by retrograde urethrography. Immediate surgical closure of urethral
injuries is recommended primarily in penetrating injuries of the anterior urethra. Straddle
injuries of the anterior urethra are initially treated with suprapubic (SP) or urethral urinary
drainage and are at high risk for delayed stricture formation. Attempts at immediate sutured
repair of posterior urethral injury are associated with unacceptably high rates of erectile
dysfunction and urinary incontinence.22 Regardless of the type of injury, securing catheter
drainage of the bladder is the immediate goal of treatment. In females, urethral injuries

Morey et al. Page 6
occur almost exclusively as a result of pelvic fracture and should be suspected in patients
having labial edema and/or blood in the vaginal vault during pelvic exam.
Immediate management of posterior urethral injuries remains controversial. Traditional

management of pelvic fracture urethral injury (PFUI) is placement of a suprapubic tube
(SPT) and delayed urethroplasty to reconnect the ruptured urethra. As endoscopic equipment
and techniques have improved over the past two decades, primary realignment (PR) of
posterior urethral ruptures has become more common. Primary realignment refers to
advancing a urinary catheter across the ruptured urethra. The goal of PR is to allow a partial
urethral injury to heal while diverting the urine via the catheter, or to align both ends of the
disrupted urethra so that they heal in the correct position as the pelvic hematoma is
reabsorbed. Review of the literature of the incidence of urethral stenosis after primary
realignment is variable, ranging from 14 to 100%.23-25 Concern surrounding primary
realignment centers on problems with the definition of success and whether patients in these
studies have had appropriate follow-up evaluation, as most eventually require repeated
instrumentation and/or formal urethroplasty to maintain patency.26
Genital Injuries—Genital injuries are a heterogeneous group of injuries, including blunt

injuries, penetrating, amputation, bite, burn, or avulsion injuries to the penis, scrotum, or
testicles in males and the vulva in females. There is little epidemiologic data for genital
injuries, although one-half to two-thirds of penetrating genitourinary injuries involve the
external genitalia.27 The most commonly encountered injuries are penile fracture, testicular
rupture, and penetrating penile injuries.
Penile fracture refers to a rupture of the tunica albuginea of the penis as a result of forceful
bending of the erect penis, most commonly during sexual intercourse in the United States. It
may be associated with urethral injury in 10-22% of cases.28 Diagnosis is usually confirmed
by clinical history of forceful bending of the erect penis, an audible “pop” or “snap,” rapid
detumescence, and penile ecchymosis. In equivocal cases, ultrasound or magnetic resonance
imaging (MRI) may clarify the diagnosis. Surgical exploration and repair is associated with
lower risk of erectile dysfunction and penile curvature.29
Blunt scrotal trauma may lead to rupture of the tunica albuginea of the testicle in 50% of
cases presenting for evaluation.30 Ultrasound may confirm or imply testicular rupture, which
should prompt exploration and attempt at repair. Early exploration is associated with higher
testicular salvage rates.30 Penetrating injuries to the scrotum should undergo surgical
exploration as over 50% will have testicular rupture.31
Penetrating penile injuries may be associated with concomitant urethral injuries in 11-29%
of cases.31 All but the most superficial injuries should be evaluated for urethral injury,
explored, and repaired. Penile amputation is a rare injury that is usually self-inflicted and
associated with extreme mental illness.32 Replantation can be successful with prompt
treatment, especially with microvascular repair.

Morey et al. Page 7
GUIDELINE STATEMENTS
Renal Trauma
Guideline Statement 1.
Clinicians should perform diagnostic imaging with intravenous (IV) contrast enhanced
computed tomography (CT) in stable blunt trauma patients with gross hematuria or
microscopic hematuria and systolic blood pressure < 90mmHG. (Standard; Evidence
Strength: Grade B)
These criteria should allow early and accurate detection and staging of significant renal
injuries. Advantages of CT outweigh the risks, which include contrast related complications,
radiation exposure, and the dangers of transporting a patient away from the resuscitation
environment into the CT scanner.33 Generally, children can be imaged using the same
criteria as adults. Children, however, often do not exhibit hypotension as adults do.
The AAST organ injury scale for renal trauma is widely used to classify and standardize
renal injuries.34 This injury grading scale has been validated as predictive of morbidity and
need for intervention to treat higher grade injuries.35-37 The system has ambiguity when
staging high-grade injuries,38 however, and several authors have proposed modification of
this grading scale to better guide therapy39 or to address ambiguity in staging injuries.40
There has been no formal revision of the AAST injury scale.
Clinicians should perform diagnostic imaging with IV contrast enhanced CT in stable

trauma patients with mechanism of injury or physical exam findings concerning for renal
injury (e.g., rapid deceleration, significant blow to flank, rib fracture, significant flank
ecchymosis, penetrating injury of abdomen, flank, or lower chest). (Recommendation;
Evidence Strength: Grade C)
Up to 34% of multisystem trauma patients may have renal injury despite absence of
hematuria or hemodynamic instability.41 A lack of these findings should not preclude
imaging if clinicians suspect renal injury based on physical findings, associated abdominal
injuries, or mechanism of injury.33
Clinicians should perform IV contrast enhanced abdominal/pelvic CT with immediate and

delayed images when there is suspicion of renal injury. (Clinical Principle)
CT scan of the abdomen and pelvis, using IV contrast with immediate and delayed phases is
preferred in order to elucidate both the location of renal lacerations and the presence of
contrast extravasation from collecting system injuries. Standard intravenous pyelogram
(IVP) may be used in rare cases where CT is not available, but is inferior. Ultrasound may
be used in children, although CT is preferred.42 Although it is not a sensitive test for
urologic injury,43 an intraoperative one -shot IVP (2 mL/kg IV bolus of contrast with a

Morey et al. Page 8
single image obtained 10-15 minutes later) may be used to confirm that a contralateral
functioning kidney is present in rare cases where the patient is taken to the operating room
without preliminary CT scan if surgeons are considering renal exploration or
nephrectomy.44
Clinicians should use non-invasive management strategies in hemodynamically stable

patients with renal injury. (Standard; Evidence Strength: Grade B)
Stable patients are defined as those who do not have vital signs consistent with shock and
show stable serial hematocrit values over time. Noninvasive management of renal injury,
which may consist of close hemodynamic monitoring, bed rest, ICU admission and blood
transfusion, avoids unnecessary surgery, decreases unnecessary nephrectomy, and preserves
renal function.45 Patients initially managed noninvasively may still require surgical,
endoscopic, or angiographic treatments at a later time, especially those with higher grade
injuries. Although devitalized parenchyma has been suggested as a risk factor for
development of septic complications, evidence supporting intervention for this radiographic
finding is inconclusive.
The surgical team must perform immediate intervention (surgery or angioembolization in

selected situations) in hemodynamically unstable patients with no or transient response to
resuscitation. (Standard; Evidence Strength: Grade B)
Hemodynamic instability despite resuscitation suggests uncontrolled and ongoing bleeding.

Immediate intervention (either open surgery or angioembolization) is warranted for unstable
patients to limit the need for future transfusion and prevent life-threatening complications.
The goal of operative exploration of an injured kidney is to control bleeding first, repair the
kidney (when possible), and establish perirenal drainage. Surgeons may perform one-shot
IVP prior to renal exploration to document function of the contralateral, uninjured kidney
using 2 mL/kg IV contrast and a single delayed image at 10-15 minutes. The benefit of prior
vascular control in the modern series examined in this Guideline are inconclusive46,47,
although older studies suggest that it is beneficial. Nephrectomy is a frequent result when
hemodynamically unstable patients undergo surgical exploration.48,49
Selected patients with bleeding from segmental renal vessels may benefit from
angioembolization as an effective yet minimally invasive treatment to control bleeding.50
Angioembolization may be appropriate in centers where experienced interventional
radiologists are immediately available. Direct communication between the clinician and
angiographer is critical. Patients who are hemodynamically unstable despite active
resuscitation should be taken to the operating room rather than angiography, which is
usually time-intensive and remote from the intensive care unit and the operating room.
Selective angioembolization should be used when possible to preserve renal function.
Recent studies suggest that additional CT findings such as IV contrast extravasation and/or

Morey et al. Page 9
large perirenal hematoma, may help predict which patients will eventually need intervention
for bleeding complications.39,51,52
Clinicians may initially observe patients with renal parenchymal injury and urinary
extravasation. (Clinical Principle)
Parenchymal collecting system injuries often resolve spontaneously. A period of observation

without intervention is advocated in stable patients where renal pelvis or proximal ureteral
injury is not suspected, preventing the risk of injury during stent placement, risk of
anesthesia, or risk of retained stent through lack of follow-up. When renal pelvis or proximal
ureteral avulsion is suspected (e.g., a large medial urinoma or contrast extravasation on
delayed images without distal ureteral contrast) prompt intervention, either endoscopic or
open depending on the clinical scenario, is warranted. Rare cases of acute renovascular
hypertension have been described, and can be treated with antihypertensives, observation, or
uncommonly, nephrectomy.
Clinicians should perform follow-up CT imaging for renal trauma patients having either (a)
deep lacerations (AAST Grade IV-V) or (b) clinical signs of complications (e.g., fever,
worsening flank pain, ongoing blood loss, abdominal distention). (Recommendation;
Follow-up CT imaging (after 48 hours) is prudent in patients with deep renal injuries (AAST
Grade IV-V) because these are prone to developing troublesome complications such as
urinoma or hemorrhage. AAST Grade I-III injuries have a low risk of complications and
rarely require intervention.39,53 Routine follow-up CT imaging is not advised for
uncomplicated AAST Grade IIII injuries because it is not likely to change clinical
management in these cases.54-61 Routine DMSA or other functional nuclear scans are also
not advised. Benefits of forgoing routine follow-up imaging in low-grade renal injuries
include simplicity in follow-up, decreased radiation exposure and IV contrast complications,
patient convenience, and lower cost. Clinicians should not hesitate to perform follow-up
imaging studies when a complication of renal injury is suspected. Periodic monitoring of
blood pressure up to a year after the injury may uncover the rare instances of post-injury
renovascular hypertension.
Clinicians should perform urinary drainage in the presence of complications such as

enlarging urinoma, fever, increasing pain, ileus, fistula or infection. (Recommendation;
Evidence Strength: Grade C) Drainage should be achieved via ureteral stent and may be
augmented by percutaneous urinoma drain, percutaneous nephrostomy or both. (Expert
Opinion)
An internalized ureteral stent is minimally invasive and alone may provide adequate
drainage of the injured kidney.62 Clinicians must make adequate provision to ensure

Morey et al. Page 10
removal of stent in follow-up. A period of concomitant Foley catheter drainage may

minimize pressure within the collecting system and enhance urinoma drainage. If follow-up
imaging demonstrates a urinoma increasing in size, purulence, or complexity, a
percutaneous drain may also be necessary.
Ureteral Trauma
Guideline Statement 9a.
Clinicians should perform IV contrast enhanced abdominal/pelvic CT with delayed imaging

(urogram) for stable trauma patients with suspected ureteral injuries. (Recommendation;
Ureteral injuries should be suspected in complex, multisystem abdominopelvic trauma

patients, such as those with bowel, bladder, or vascular injuries; in those with complex
pelvic/vertebral fractures; after rapid deceleration injuries; and when the trajectory of the
penetrating injury is near the ureter, especially with high velocity gunshot wounds.63,64
Absence of hematuria cannot be relied upon to exclude ureteral injury.65 In stable patients
not proceeding directly to exploratory laparotomy, IV contrast enhanced abdominal/pelvic
CT with 10 minute delayed images should be obtained to evaluate for ureteral injury.
Findings suggestive of ureteral injury include contrast extravasation, ipsilateral delayed
pyelogram, ipsilateral hydronephrosis, and lack of contrast in the ureter distal to the
suspected injury.66-68 If the initial delayed images do not adequately opacify the ureters,
further delayed imaging may be necessary if ureteral injury is still suspected.
Guideline Statement 9b.
Clinicians should directly inspect the ureters during laparotomy in patients with suspected
ureteral injury who have not had preoperative imaging. (Clinical Principle)
Direct ureteral inspection is necessary in patients suspected to have ureteral injury who
proceed directly to laparotomy without adequate radiographic staging. Adjunctive
maneuvers to identify ureteral injuries include careful ipsilateral ureteral mobilization and/or
IV or intraureteral injectable dyes such as methylene blue or indigo carmine. Retrograde
pyelography may be performed in equivocal cases when possible. Intraoperative single-shot
IVP cannot reliably exclude ureteral injury and should not be used solely for this purpose.
Surgeons should repair traumatic ureteral lacerations at the time of laparotomy in stable
patients. (Recommendation; Evidence Strength: Grade C)
Ureteral repair should be performed at the time of initial laparotomy, when possible, though
immediate repair may not be appropriate in unstable, complex polytrauma patients.69-74
Surgeons may manage ureteral injuries in unstable patients with temporary urinary drainage
followed by delayed definitive management. (Clinical Principle)

In damage control settings when immediate ureteral repair is not possible at time of initial
laparotomy, urinary extravasation can be prevented with ureteral ligation followed by
percutaneous nephrostomy tube placement or with an externalized ureteral catheter secured
to the proximal end of the ureteral defect. Definitive repair of the injury should be
performed when the patient’s clinical situation has improved/ stabilized.
Guideline Statement 10c.
Surgeons should manage traumatic ureteral contusions at the time of laparotomy with
ureteral stenting or resection and primary repair depending on ureteral viability and clinical
scenario. (Expert Opinion)
Ureteral contusion is not uncommon in the context of a gunshot wound with blast injury;
complications may include delayed ureteral stricture and/or overt ureteral necrosis with
urinary extravasation. Thus, when identified during laparotomy, intact but contused ureters
should be primarily managed with ureteral stenting; resection with primary repair may be
performed in selected instances, particularly after gunshot wounds, depending on the
severity of the contusion and the viability of local tissues.
Surgeons should attempt ureteral stent placement in patients with incomplete ureteral
injuries diagnosed postoperatively or in a delayed setting. (Recommendation; Evidence
Strength: Grade C)
When an incomplete ureteral injury is at first unrecognized or presents in a delayed fashion,

retrograde ureteral imaging with ureteral stent placement should be performed initially.75-81
Immediate repair can be considered in certain clinical situations if the injury is recognized
within one week (e.g., injury located near a surgically closed viscus, such as bowel or
vagina, or if the patient is being re-explored for other reasons).
Surgeons should perform percutaneous nephrostomy with delayed repair as needed in

patients when stent placement is unsuccessful or not possible. (Recommendation; Evidence
Strength: Grade C)
When the proximal ureter is completely transected or otherwise cannot be cannulated in a

retrograde fashion, or if patient instability precludes attempts at retrograde treatment, a
percutaneous nephrostomy tube should be placed. If nephrostomy alone does not adequately
control the urine leak, options then include placement of a periureteral drain or immediate
open ureteral repair.75-83
Surgeons should repair ureteral injuries located proximal to the iliac vessels with primary
repair over a ureteral stent, when possible. (Recommendation; Evidence Strength: Grade C)

When the ureter is injured above the iliac vessels, a spatulated, tension-free primary ureteral
repair over a ureteral stent is advisable after all non-viable ureteral tissue has been
judiciously debrided. In situations where the anastomosis cannot be performed without
tension, mobilization of the ureter should be performed in a manner that preserves maximal
ureteral blood supply. If an anastomosis can still not be performed after mobilization, a
ureteral reimplantation can be attempted, incorporating ancillary maneuvers such as a
bladder psoas hitch and/or Boari bladder flap. Interposition with bowel and autotransplant
are not recommended in the acute setting. If the injury cannot be managed adequately in the
acute setting, ureteral ligation with percutaneous nephrostomy tube placement is advised
followed by delayed ureteral reconstruction.63,65,74,84-88
Surgeons should repair ureteral injuries located distal to the iliac vessels with ureteral
reimplantation or primary repair over a ureteral stent, when possible. (Recommendation;
When the ureter is injured below the iliac vessels, the distal ureter may be healthy enough to
perform a simple ureteroureterostomy in select situations, although the surgeon should defer
to direct ureteral reimplantation if there is any doubt about the segment’s viability. Tension-
free reimplantation may require ancillary maneuvers such as a bladder mobilization with
psoas hitch or flap. Interposition with bowel is not recommended in the acute setting. If the
injury cannot be managed adequately in the acute setting, ureteral ligation with percutaneous
nephrostomy tube placement is advised followed by delayed ureteral
reconstruction.63,65,74,84-88
Surgeons should manage endoscopic ureteral injuries with a ureteral stent and/or
percutaneous nephrostomy tube, when possible. (Recommendation; Evidence Strength:
Grade C)
When a ureteral injury occurs during ureteral endoscopy, a ureteral stent should be placed. If
placement of a ureteral stent is not possible or if stent placement fails to adequately divert
the urine, then a percutaneous nephrostomy tube should be placed with or without a
periureteral drain. Delayed ureteral reconstruction is often necessary.76,89-91
Surgeons may manage endoscopic ureteral injuries with open repair when endoscopic or
percutaneous procedures are not possible or fail to adequately divert the urine. (Expert
Opinion)
Open or laparoscopic repair of endoscopic ureteral injuries, using techniques and principles
mentioned above, is necessary when endoscopic attempts at diverting the urine fail.75,79,83

Bladder Trauma
Clinicians must perform retrograde cystography (plain film or CT) in stable patients with
gross hematuria and pelvic fracture. (Standard; Evidence Strength: Grade B)
Gross hematuria is the most common indicator of bladder injury.19,92-102 Pelvic fracture is
the most common associated injury with bladder rupture;19,94,95,99,100,103-105 however,
pelvic fracture alone does not warrant radiologic evaluation of the bladder.98 Bladder injury
is present in 29% of the patients presenting with the combination of gross hematuria and
pelvic fracture; therefore, gross hematuria occurring with pelvic fracture is considered an
absolute indication for retrograde cystography to evaluate for the presence of bladder
injury.19
Retrograde cystography is the technique of choice to diagnose bladder injury. Plain film and
CT cystography have been shown to have a similar specificity and sensitivity.94,106 Both
techniques are highly accurate for the diagnosis of bladder rupture. The choice of imaging
modality is largely left to clinician preference, equipment availability, imaging requirements
for other associated injuries, patient stability, and ease of testing.
The technique for plain film cystography consists of retrograde, gravity filling of the bladder
with contrast. The volume instilled should be a minimum of 300 mL or until the patient
reaches tolerance in order to maximally distend the bladder.94,106 A minimum of two views
is required, the first at maximal fill and the second after bladder drainage. Additional films
can be obtained, such as oblique views, which may provide more information but are not
required. CT cystogram is performed in a similar fashion using dilute water-soluble contrast
to prevent artifacts from obscuring visualization. Simply clamping a Foley catheter to allow
excreted IV-administered contrast to accumulate in the bladder is not appropriate. This
technique will not provide adequate bladder distention and results in missed bladder
injuries.94,95,106
Clinicians should perform retrograde cystography in stable patients with gross hematuria
and a mechanism concerning for bladder injury, or in those with pelvic ring fractures and
clinical indicators of bladder rupture. (Recommendation; Evidence Strength: Grade C)
Although the majority of bladder ruptures (>90%) will present with gross hematuria in the
setting of a pelvic ring fracture, a number of other clinical scenarios should warrant
retrograde cystography to evaluate for bladder injury.19,107 A limited number of pelvic
fracture patients with bladder injuries will present with microscopic hematuria
(0.6-5.0%).19,103 In general, microscopic hematuria combined with pelvic fracture is not an
indication for radiologic evaluation, but may be warranted in select cases.19,94,103,105,108
Certain fracture patterns including pubic symphysis diastasis and obturator ring fracture
displacement of greater than 1 cm have been shown as indicators of potential bladder
injury.103 Other indicators of potential bladder rupture include: the inability to void, low
urine output, increased BUN and creatinine secondary to peritoneal absorption of urine,

abdominal distention, suprapubic pain, and low density free intraperitoneal fluid on
abdominal imaging (urinary ascites).19,105,108 Gross or microscopic hematuria in the
presence of penetrating injuries with pelvic trajectories requires radiological, endoscopic or
surgical evaluation of the bladder.
Surgeons must perform surgical repair of intraperitoneal bladder rupture in the setting of
blunt or penetrating external trauma. (Standard; Evidence Strength: Grade B)
Intraperitoneal bladder ruptures must be repaired.19,93,96,98,101,106,109-113 Intraperitoneal

ruptures caused by blunt external trauma tend to be large “blow -out” injuries located in the
dome of the bladder and are unlikely to heal spontaneously with catheter drainage alone.
Penetrating injuries with intraperitoneal components generally have smaller injuries but
must be repaired as well. Failure to repair intraperitoneal bladder injuries can result in
translocation of bacteria from the bladder to the abdominal cavity resulting in peritonitis,
sepsis, and other serious complications. During surgical repair of the bladder, the integrity of
the bladder neck and ureteral orifices should be confirmed and repair considered if injured.
Delays in surgical repair may occur in those patients who are unable to undergo immediate
surgical repair, (i.e., the unstable patient). Repair of intraperitoneal bladder injuries should
be expedited when medically feasible. While many are repaired by open surgery,
laparoscopic repair of isolated intraperitoneal injuries is appropriate in certain instances.114
Follow-up cystography should be used to confirm bladder healing in complex repairs but
may not be necessary in more simple repairs.110
Clinicians should perform catheter drainage as treatment for patients with uncomplicated
extraperitoneal bladder injuries. (Recommendation; Evidence Strength: Grade C)
Uncomplicated extraperitoneal bladder injuries can be managed using urethral Foley

catheter drainage with the expectation that the injury will heal with conservative
management.95,96,98,101,109,110,112,113 Leaving the Foley catheter in place two to three
weeks is standard, although in the setting of significant concurrent injuries, it is acceptable
to leave the Foley catheter in longer. Consideration for open repair may be appropriate in
those patients with non-healing bladder injuries who are unresponsive to Foley catheter
drainage greater than four weeks. Follow-up cystography should be used to confirm that the
extraperitoneal bladder injury has healed after treatment with catheter drainage.110
Surgeons should perform surgical repair in patients with complicated extraperitoneal bladder
injury. (Recommendation; Evidence Strength: Grade C)
Complicated extraperitoneal bladder ruptures should be surgically repaired in the standard

fashion to avoid prolonged sequelae from the injury. Extraperitoneal bladder ruptures are
considered complex in a number of settings. Pelvic fractures that result in exposed bone
spicules in the bladder lumen should be repaired with removal of the exposed bone and

closure of the bladder. Concurrent rectal or vaginal lacerations may lead to fistula formation
to the ruptured bladder, and in this setting the extraperitoneal bladder rupture should be
fixed. Bladder neck injuries may not heal with catheter drainage alone and repair should be
considered. In circumstances where the patient is undergoing open reduction internal

fixation or repair of abdominal injuries, the clinician should consider performing bladder
repair for extraperitoneal bladder injury given that the typical bladder repair can be
performed quickly and with little morbidity.19,98,109,110,115 Follow-up cystography should
be used to confirm that the complex, extraperitoneal bladder injury has healed.110
Clinicians should perform urethral catheter drainage without suprapubic (SP) cystostomy in
patients following surgical repair of bladder injuries. (Standard; Evidence Strength: Grade
B)
A number of studies have shown no advantage of combined SP and urethral catheterization

over urethral catheterization alone after repair of bladder injuries. Urethral catheters have
been shown to adequately drain the repaired bladder and result in shorter hospital stay and
lower morbidity.19,111,116-118
There are clinical exceptions in which SPTs may be considered; such exceptions include
patients requiring long-term catheterization, such as those with severe neurological injuries
(i.e., head and spinal cord), those immobilized due to orthopedic injuries, and complex
bladder repairs with tenuous closures or significant hematuria.
Urethral Trauma
Clinicians should perform retrograde urethrography in patients with blood at the urethral
meatus after pelvic trauma. (Recommendation; Evidence Strength: Grade C)
Given concerns for urethral injury, clinicians should perform retrograde urethrography after
pelvic or genital trauma when blood is seen at the urethral meatus.119,120 The retrograde
urethrogram may demonstrate partial or complete urethral disruption, providing guidance for
how to best manage bladder drainage in the acute setting. Blind catheter passage prior to
retrograde urethrogram should be avoided,121 unless exceptional circumstances indicate an

attempt at emergent catheter drainage for monitoring. In the acute setting of a partial urethral
disruption, a single attempt with a well-lubricated catheter may be attempted by an
experienced team member.
A retrograde urethrogram is performed by positioning the patient obliquely with the bottom
leg flexed at the knee and the top leg kept straight. If severe pelvic or spine fractures are
present, leaving the patient supine and placing the penis on stretch to acquire the image is
appropriate. A 12Fr Foley catheter or catheter tipped syringe is introduced into the fossa
navicularis, the penis is placed on gentle traction and 20 mL undiluted water soluble contrast
material is injected with the image acquired.

Occasionally a Foley catheter has been placed before evaluating the urethra. Further imaging
is not warranted if no meatal blood is present and suspicion of injury is low. If blood is
present a pericatheter retrograde urethrogram should be performed to identify potential
missed urethral injury. This is done by injecting contrast material through a 3Fr catheter or
angiocatheter held in the fossa navicularis to distend the urethra and prevent contrast leak
per meatus.
Clinicians should establish prompt urinary drainage in patients with pelvic fracture
associated urethral injury. (Recommendation; Evidence Strength: Grade C)
Patients with pelvic fracture urethral injury (PFUI) are often unable to urinate due to their
injuries.120 Trauma resuscitations typically involve aggressive hydration and a critical need
to closely monitor patient volume status. Whether through SPT drainage or urethral catheter,
clinicians should establish efficient and prompt urinary drainage in the acute setting. SPT
may be placed percutaneously or via open technique, depending on clinical setting. Small
caliber percutaneous catheters will require upsizing in the setting of hematuria, prolonged
use or in anticipation for future definitive surgical repair. Repeated attempts at placing a
urethral catheter should be avoided given the likelihood of increasing injury extent and
delaying drainage.
Surgeons may place suprapubic tubes (SPTs) in patients undergoing open reduction internal
fixation (ORIF) for pelvic fracture. (Expert Opinion)
The management of PFUI requires close coordination with orthopedic surgeons to optimize
timing of interventions. In such cases, concerns regarding the use of SPT in patients
undergoing open reduction and internal fixation of the pubic symphysis vary based on
individual surgeon and institutional practice patterns. No evidence exists to indicate that
SPT insertion increases the risk of orthopedic hardware infection.116,122 Thus,
considerations of the urethral injury and its management should dictate the use of SPT.
Particular circumstances, such as gross fecal contamination or open fractures, may suggest
exceptions to these general observations.
Clinicians may perform primary realignment (PR) in hemodynamically stable patients with
pelvic fracture associated urethral injury. (Option; Evidence Strength: Grade C) Clinicians
should not perform prolonged attempts at endoscopic realignment in patients with pelvic
fracture associated urethral injury. (Clinical Principle)
The first priority in management of PFUI is establishment of urinary drainage. SPT and
delayed urethral reconstruction remains the accepted treatment for the vast majority of cases.
Patients undergoing PR of PFUI may have less severe urethral strictures when compared to
patients undergoing SP diversion alone.23,24

Although the indications, benefits, and methods of PR remain debatable, attempts at PR

should be reserved for hemodynamically stable patients within the first few days after
injury.27 124 The technique may require two urologists to navigate the urethra
simultaneously from above and below with multiple flexible or rigid cystoscopes, video
monitors, and fluoroscopy. These requirements are best met by a regular urology operating
room team once the patient has stabilized in coordination with trauma and orthopedic
surgeons, thus the Emergency Department setting is inappropriate for realignment of most
PFUI. Prolonged and heroic attempts at endoscopic realignment must be avoided as the
process may increase injury severity and long-term sequelae, delay other medical services
the patient requires, and has not been shown to improve long-term outcomes. Whether
endoscopic realignment is successfully performed or not, patients with pelvic fracture
associated urethral injury are at high risk for developing urethral stricture, and thus after PR
it may be prudent to maintain SPT drainage while awaiting resolution of PFUI.
Clinicians should monitor patients for complications (e.g., stricture formation, erectile
dysfunction, incontinence) for at least one year following urethral injury. (Recommendation;
PFUI is associated with high rates of urethral stricture formation and erectile dysfunction,
while only small numbers of men will report urinary incontinence.120,123 Rates of stricture
after PFUI will vary based on injury severity and management with PR or SPT, but in either
scenario, stricture in most cases develops within a year of injury and can be treated by
urethroplasty or direct vision internal urethrotomy.22,125 Thus surveillance strategies with
uroflowmetry, retrograde urethrogram, cystoscopy, or some combination of methods are
recommended for the first year after injury. Impotence and incontinence are generally
considered to be caused by the pelvic fracture itself rather than contemporary interventions
for PFUI.126,127
Surgeons should perform prompt surgical repair in patients with uncomplicated penetrating
trauma of the anterior urethra. (Expert Opinion)
After a penetrating trauma to the anterior urethra has been appropriately staged, surgical
repair should be performed. It is expert opinion that spatulated primary repair of
uncomplicated injuries in the acute setting offers excellent outcomes superior to delayed
reconstruction. Primary repair should not be undertaken if the patient is unstable, the
surgeon lacks expertise in urethral surgery or in the setting of extensive tissue destruction or
loss.
Clinicians should establish prompt urinary drainage in patients with straddle injury to the
anterior urethra. (Recommendation; Evidence Strength: Grade C)

Crush injuries of the bulbar urethra caused by straddle injury require prompt intervention to
avoid urinary extravasation.128 Establishing urinary drainage by SPT, or PR in less severe
cases, requires consideration of associated injuries, severity of the disruption, degree of
bladder distension, and availability of urological expertise and endoscopic instrumentation.

Immediate operative intervention to repair or debride the injured urethra is contraindicated
due to the indistinct nature of the injury border. Stricture formation after straddle injury is
very high and thus all patients undergoing urinary diversion require follow-up surveillance
using uroflowmetry, retrograde urethrogram and/or cystoscopy.129
Genital Trauma
Clinicians must suspect penile fracture when a patient presents with penile ecchymosis,
swelling, cracking or snapping sound during intercourse or manipulation and immediate
detumescence. (Standard; Evidence Strength: Grade B)
Penile swelling and ecchymosis are the most common symptoms of penile fracture. Most
patients report a cracking or snapping sound followed by immediate detumescence. Other
symptoms may include penile pain and penile angulation. History and physical examination
alone are often diagnostic in patients with these presenting symptoms.29,130-140
Surgeons should perform prompt surgical exploration and repair in patients with acute signs
and symptoms of penile fracture. (Standard; Evidence Strength: Grade B)
In patients with historical and physical signs consistent with penile fracture, surgical repair
should be performed. The repair is performed by exposing the injured corpus cavernosum
through either a ventral midline or circumcision incision. Tunical repair is performed with
absorbable suture and should be performed at the time of presentation to improve long-term
patient outcomes.130,132,137,141-148
Clinicians may perform ultrasound in patients with equivocal signs and symptoms of penile
fracture. (Expert Opinion)
Patients with equivocal signs of penile fracture may undergo imaging as an adjunct study to
assist with confirmation or exclusion of the diagnosis of penile fracture.149 Ultrasound is the
most commonly used imaging modality due to wide availability, low cost, and rapid
examination times.141,142 MRI could be considered in cases when ultrasound is
equivocal.131 If imaging is equivocal or diagnosis remains in doubt, surgical exploration
should be performed.

Clinicians must perform evaluation for concomitant urethral injury in patients with penile
fracture or penetrating trauma who present with blood at the urethral meatus, gross
hematuria or inability to void. (Standard; Evidence Strength: Grade B)
Patients with penile fracture and gross hematuria, blood at the urethral meatus, or inability to
void should undergo evaluation for concomitant urethral injury.138,150-152 An additional risk
factor is bilateral corporal body fracture.130,153,154 Options for evaluation include
urethroscopy and retrograde urethrogram.140,144,146,148,149,155 Neither method is superior
for diagnosis. The choice of retrograde urethrogram or cystoscopy is the decision of the
urologist based on availability of equipment and timing of the procedure.
Surgeons should perform scrotal exploration and debridement with tunical closure (when
possible) or orchiectomy (when non-salvagable) in patients with suspected testicular rupture.
(Standard; Evidence Strength: Grade B)
Testicular rupture after blunt or penetrating scrotal injuries may be suggested by scrotal
ecchymosis and swelling or difficulty in identifying the contours of the testicle on physical
exam. The most specific findings on ultrasonography are loss of testicular contour and
heterogenous echotexture of parenchyma, which should prompt testicular repair.156 Early
exploration and repair may prevent complications, such as ischemic atrophy of the testis and
infection.157 Repair of the ruptured testis by debriding non-viable tissue and closing the
tunica albuginea is preferred when possible.157,158 Scrotal injury may raise the suspicion of
concomitant urethral injury. Expert opinion is that tunica vaginalis grafts may be used to
provide closure when the tunica albuginea cannot be closed primarily. For penetrating
scrotal injuries, immediate exploration with debridement and repair is encouraged to prevent
complications.
Surgeons should perform exploration and limited debridement of non-viable tissue in

patients with extensive genital skin loss or injury from infection, shearing injuries, or burns
(thermal, chemical, electrical). (Standard; Evidence Strength: Grade B)
Initial management in these patients should include operative exploration, irrigation, and
limited debridement of clearly non-viable tissue.159-174 Genital skin is well vascularized and
tissues with marginal viability may survive due to collateral blood flow. Typically, these
injuries require multiple procedures in the operating room prior to definitive reconstructive
procedures. Wound management can include a variety of methods including gauze dressings
with frequent changes, silver sulfadiazine or topical antibiotic and occlusive dressing, or
negative pressure dressings.159,161-163,167,171,175-179 Reconstructive techniques for definitive
repair include primary closure and advancement flaps, placement of skin grafts, free tissue
flaps, and pedicle based skin flaps.161-163,165,166,170,180-185

Surgeons should perform prompt penile replantation in patients with traumatic penile
amputation, with the amputated appendage wrapped in saline-soaked gauze, in a plastic bag
and placed on ice during transport. (Clinical Principle)
Urologists should perform re-anastomosis of macroscopic structures, including the corpora

cavernosa, spatulated repair of the urethra, and skin, when the amputated penis is available.
A microvascular surgeon should be consulted whenever possible to perform microscopic
repair of dorsal arteries, veins, and nerves. Microvascular repair may improve outcomes,
especially with respect to loss of penile skin. Transfer to a center with these capabilities can
be considered for this reason. The amputated appendage should be transported to the
hospital in a two-bag system, with the penis wrapped in saline-soaked gauze, placed in a
plastic bag, and then placed on ice in a second bag.
FUTURE RESEARCH
As the field of genitourinary reconstruction continues to evolve, clinicians must strive to
approach clinical problems in a creative, multi-disciplinary, evidence-based manner to
ensure optimal outcomes. Further research is needed to clarify which radiographic indicators
of renal injuries can be used to facilitate selection of appropriate candidates for angiographic
embolization. Complex ureteral defects are increasingly amenable to robotic repair, and
further study is needed to clarify the role of classic reconstructive techniques, such as Boari
flap, ileal ureter, and downward nephropexy in the robotic era. Evaluation of the existing
literature does not demonstrate conclusively whether or when PR of urethral disruption
injuries is advantageous over initial SP urinary diversion alone followed by definitive
delayed urethroplasty. Similarly, the role of SPT placement remains controversial in pelvic
fracture urethral injury patients who are candidates for internal pubic fixation procedures.
Genital injuries are rarely life threatening, but they often become the male trauma patient’s
chief concern once acute issues are resolved. Plastic surgical principles offer an important
guide for optimal genital cosmesis and function. Further study is needed in the areas of
tissue engineering, tissue glues, and wound healing biology to optimize outcomes.
Acknowledgments
Peer Reviewers
We are grateful to the persons listed below who contributed to the Urotrauma Guideline by providing comments
during the peer review process. Their reviews do not necessarily imply endorsement of the Guideline.
Howard L. Adler, MD, FACS
William W. Bohnert, MD
Jill C. Buckley, MD
Daniel J. Culkin, MD
Branden Glenn Duffey, DO
Michael Louis Eisenberg, MD
Christopher Michael Gonzalez, MD

Tomas L. Griebling, MD, MPH
C. D. Anthony Herndon, MD
Courtney M.P. Hollowell, MD, FACS
Jeff Holzbeierlein, MD
Saqib Javed, MBBS
Jerry Jurkovich, MD
Gerald Patrick Kealey, MD
Kirk A. Keegan III, MD
Ron T. Kodama, MD
Granville Lloyd, MD
Kevin R. Loughlin, MD, MBA
Chris McClung, MD
Jay A. Motola, MD
Jeremy B. Myers MD
Stephen Y. Nakada, MD, FACS
Thomas E. Novak, MD
Andrew C. Peterson, MD
Timothy Martin Phillips, MD
Kevin McVary, MD
Maniyur Raghavendran, MD
Hassan Razvi, MD
Pramod C. Sogani, MD
John T. Stoffel, MD
Ryan Terlecki, MD
Christopher Douglas Tessier, MD
Alex Vanni, MD
J. Stuart Wolf, Jr., MD
Lawrence Yeung, MD
DISCLAIMER This document was written by the Urotrauma Guidelines Panel of the American Urological
Association Education and Research, Inc., which was created in 2013. The Practice Guidelines Committee (PGC)
of the AUA selected the committee chair. Panel members were selected by the chair. Membership of the committee
included urologists and other clinicians with specific expertise on this disorder. The mission of the committee was
to develop recommendations that are analysis-based or consensus-based, depending on Panel processes and
available data, for optimal clinical practices in the treatment kidney stones.
Funding of the committee was provided by the AUA. Committee members received no remuneration for their work.
Each member of the committee provides an ongoing conflict of interest disclosure to the AUA.

While these guidelines do not necessarily establish the standard of care, AUA seeks to recommend and to
encourage compliance by practitioners with current best practices related to the condition being treated. As medical
knowledge expands and technology advances, the guidelines will change. Today these evidence-based guidelines
statements represent not absolute mandates but provisional proposals for treatment under the specific conditions
described in each document. For all these reasons, the guidelines do not pre-empt physician judgment in individual
cases.
Treating physicians must take into account variations in resources, and patient tolerances, needs, and preferences.
Conformance with any clinical guideline does not guarantee a successful outcome. The guideline text may include
information or recommendations about certain drug uses (‘off label’) that are not approved by the Food and Drug
Administration (FDA), or about medications or substances not subject to the FDA approval process. AUA urges
strict compliance with all government regulations and protocols for prescription and use of these substances. The
physician is encouraged to carefully follow all available prescribing information about indications,
contraindications, precautions and warnings. These guidelines and best practice statements are not in-tended to
provide legal advice about use and misuse of these substances.
Although guidelines are intended to encourage best practices and potentially encompass available technologies with
sufficient data as of close of the literature review, they are necessarily time-limited. Guidelines cannot include
evaluation of all data on emerging technologies or management, including those that are FDA-approved, which
may immediately come to represent accepted clinical practices.
For this reason, the AUA does not regard technologies or management which are too new to be addressed by this
guideline as necessarily experimental or investigational.
LIST OF ABBREVIATIONS
AAST American Association for the Surgery of Trauma

BUN blood urea nitrogen
CCT Controlled clinical trial
COI Conflict of interest
CT Computed tomography
DMSA Dimercaptosuccinic acid
GOC Guidelines Oversight Committee
ICU Intensive care unit
IV Intravenous
IVP Intravenous pyelogram
J&E Judicial and ethics
MRI Magnetic resonance imaging

ORIF Open reduction internal fixation
PFUI Pelvic fracture urethral injury
PGC Practice Guidelines Committee
PR Primary realignment
RCT Randomized controlled trial
RUG retrograde urethrogram
SBP Systolic blood pressure

SP Suprapubic
SPT Suprapubic tube

UPJ Ureteropelvic junction
VCUG Voiding cystourethrogram
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GUIDELINE STATEMENTS
Renal Trauma
1. Clinicians should perform diagnostic imaging with intravenous (IV) contrast

enhanced computed tomography (CT) in stable blunt trauma patients with gross
hematuria or microscopic hematuria and systolic blood pressure < 90mmHG.
(Standard; Evidence Strength: Grade B)
2. Clinicians should perform diagnostic imaging with IV contrast enhanced CT in

stable trauma patients with mechanism of injury or physical exam findings
concerning for renal injury (e.g., rapid deceleration, significant blow to flank,
rib fracture, significant flank ecchymosis, penetrating injury of abdomen, flank,
or lower chest). (Recommendation; Evidence Strength: Grade C)
3. Clinicians should perform IV contrast enhanced abdominal/pelvic CT with

immediate and delayed images when there is suspicion of renal injury. (Clinical
Principle)
4. Clinicians should use non-invasive management strategies in hemodynamically

stable patients with renal injury. (Standard; Evidence Strength: Grade B)
5. The surgical team must perform immediate intervention (surgery or

angioembolization in selected situations) in hemodynamically unstable patients
with no or transient response to resuscitation. (Standard; Evidence Strength:
Grade B)
6. Clinicians may initially observe patients with renal parenchymal injury and
urinary extravasation. (Clinical Principle)
7. Clinicians should perform follow-up CT imaging for renal trauma patients

having either (a) deep lacerations (AAST Grade IV-V) or (b) clinical signs of
complications (e.g., fever, worsening flank pain, ongoing blood loss, abdominal
distention). (Recommendation; Evidence Strength: Grade C)
8. Clinicians should perform urinary drainage in the presence of complications

such as enlarging urinoma, fever, increasing pain, ileus, fistula or infection.
(Recommendation; Evidence Strength: Grade C) Drainage should be achieved
via ureteral stent and may be augmented by percutaneous urinoma drain,

percutaneous nephrostomy or both. (Expert Opinion)
Ureteral Trauma
9a. Clinicians should perform IV contrast enhanced abdominal/pelvic CT with
delayed imaging (urogram) for stable trauma patients with suspected ureteral
injuries. (Recommendation; Evidence Strength: Grade C)
9b. Clinicians should directly inspect the ureters during laparotomy in patients with
suspected ureteral injury who have not had preoperative imaging. (Clinical Principle)
10a. Surgeons should repair traumatic ureteral lacerations at the time of laparotomy
in stable patients. (Recommendation; Evidence Strength: Grade C)

10b. Surgeons may manage ureteral injuries in unstable patients with temporary
urinary drainage followed by delayed definitive management. (Clinical Principle)
10c. Surgeons should manage traumatic ureteral contusions at the time of

laparotomy with ureteral stenting or resection and primary repair depending on
ureteral viability and clinical scenario. (Expert Opinion)
11a. Surgeons should attempt ureteral stent placement in patients with incomplete
ureteral injuries diagnosed postoperatively or in a delayed setting.
(Recommendation; Evidence Strength: Grade C)
11b. Surgeons should perform percutaneous nephrostomy with delayed repair as
needed in patients when stent placement is unsuccessful or not possible.
12a. Surgeons should repair ureteral injuries located proximal to the iliac vessels
with primary repair over a ureteral stent, when possible. (Recommendation;
12b. Surgeons should repair ureteral injuries located distal to the iliac vessels with
ureteral reimplantation or primary repair over a ureteral stent, when possible.
13a. Surgeons should manage endoscopic ureteral injuries with a ureteral stent
and/or percutaneous nephrostomy tube, when possible. (Recommendation; Evidence
Strength: Grade C)
13b. Surgeons may manage endoscopic ureteral injuries with open repair when
endoscopic or percutaneous procedures are not possible or fail to adequately divert
the urine. (Expert Opinion)
Bladder Trauma
14a. Clinicians must perform retrograde cystography (plain film or CT) in stable
patients with gross hematuria and pelvic fracture. (Standard; Evidence Strength:
Grade B)
14b. Clinicians should perform retrograde cystography in stable patients with gross
hematuria and a mechanism concerning for bladder injury, or in those with pelvic
ring fractures and clinical indicators of bladder rupture. (Recommendation; Evidence

Strength: Grade C)
15. Surgeons must perform surgical repair of intraperitoneal bladder rupture in the
setting of blunt or penetrating external trauma. (Standard; Evidence Strength: Grade
B)
16. Clinicians should perform catheter drainage as treatment for patients with
uncomplicated extraperitoneal bladder injuries. (Recommendation; Evidence
Strength: Grade C)
17. Surgeons should perform surgical repair in patients with complicated

extraperitoneal bladder injury. (Recommendation; Evidence Strength: Grade C)

18. Clinicians should perform urethral catheter drainage without suprapubic (SP)
cystostomy in patients following surgical repair of bladder injuries. (Standard;
Evidence Strength: Grade B)
Urethral Trauma
19. Clinicians should perform retrograde urethrography in patients with blood at the
urethral meatus after pelvic trauma. (Recommendation; Evidence Strength: Grade C)
20. Clinicians should establish prompt urinary drainage in patients with pelvic
fracture associated urethral injury. (Recommendation; Evidence Strength: Grade C)
21. Surgeons may place suprapubic tubes (SPTs) in patients undergoing open
reduction internal fixation (ORIF) for pelvic fracture. (Expert Opinion)
22. Clinicians may perform primary realignment (PR) in hemodynamically stable

patients with pelvic fracture associated urethral injury. (Option; Evidence Strength:
Grade C) Clinicians should not perform prolonged attempts at endoscopic
realignment in patients with pelvic fracture associated urethral injury. (Clinical
Principle)
23. Clinicians should monitor patients for complications (e.g., stricture formation,
erectile dysfunction, incontinence) for at least one year following urethral injury.
24. Surgeons should perform prompt surgical repair in patients with uncomplicated
penetrating trauma of the anterior urethra. (Expert Opinion)
25. Clinicians should establish prompt urinary drainage in patients with straddle
injury to the anterior urethra. (Recommendation; Evidence Strength: Grade C)
Genital Trauma
26. Clinicians must suspect penile fracture when a patient presents with penile
ecchymosis, swelling, cracking or snapping sound during intercourse or
manipulation and immediate detumescence. (Standard; Evidence Strength: Grade B)
27. Surgeons should perform prompt surgical exploration and repair in patients with
acute signs and symptoms of penile fracture. (Standard; Evidence Strength: Grade B)
28. Clinicians may perform ultrasound in patients with equivocal signs and
symptoms of penile fracture. (Expert Opinion)
29. Clinicians must perform evaluation for concomitant urethral injury in patients
with penile fracture or penetrating trauma who present with blood at the urethral
meatus, gross hematuria or inability to void. (Standard; Evidence Strength: Grade B)
30. Surgeons should perform scrotal exploration and debridement with tunical
closure (when possible) or orchiectomy (when non-salvagable) in patients with
suspected testicular rupture. (Standard; Evidence Strength: Grade B) 31. Surgeons
should perform exploration and limited debridement of non-viable tissue in patients
with extensive genital skin loss or injury from infection, shearing injuries, or burns
(thermal, chemical, electrical). (Standard; Evidence Strength: Grade B)

32. Surgeons should perform prompt penile replantation in patients with traumatic
penile amputation, with the amputated appendage wrapped in saline-soaked gauze,
in a plastic bag and placed on ice during transport. (Clinical Principle)

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J Urol. 2014 August ; 192(2): 327–335. doi:10.1016/j.juro.2014.05.004.

UROTRAUMA: AUA GUIDELINE

Copyright © 2014 American Urological Association Education and Research, Inc.®

Quality of Studies and Determination of Evidence Strength—Quality of

J Urol. Author manuscript; available in PMC 2014 August 01.

The categorization of evidence strength is conceptually distinct from the quality of

AUA Nomenclature: Linking Statement Type to Evidence Strength—The AUA

be evidence in the medical literature. Expert Opinion refers to a statement, achieved by

Limitations of the Literature—The Panel proceeded with full awareness of the

J Urol. Author manuscript; available in PMC 2014 August 01.

Background & Epidemiology

J Urol. Author manuscript; available in PMC 2014 August 01.

Ureteral Injuries—Ureteral injuries are rare, accounting for 1% of urologic injuries.

Bladder Injuries—Bladder injuries occur in approximately 1.6% of blunt abdominal

J Urol. Author manuscript; available in PMC 2014 August 01.

Immediate management of posterior urethral injuries remains controversial. Traditional

Genital Injuries—Genital injuries are a heterogeneous group of injuries, including blunt

J Urol. Author manuscript; available in PMC 2014 August 01.

Clinicians should perform diagnostic imaging with IV contrast enhanced CT in stable

Clinicians should perform IV contrast enhanced abdominal/pelvic CT with immediate and

J Urol. Author manuscript; available in PMC 2014 August 01.

Clinicians should use non-invasive management strategies in hemodynamically stable

The surgical team must perform immediate intervention (surgery or angioembolization in

Hemodynamic instability despite resuscitation suggests uncontrolled and ongoing bleeding.

hemodynamically unstable patients undergo surgical exploration.48,49

J Urol. Author manuscript; available in PMC 2014 August 01.

Parenchymal collecting system injuries often resolve spontaneously. A period of observation

Clinicians should perform urinary drainage in the presence of complications such as

J Urol. Author manuscript; available in PMC 2014 August 01.

removal of stent in follow-up. A period of concomitant Foley catheter drainage may

percutaneous drain may also be necessary.

Clinicians should perform IV contrast enhanced abdominal/pelvic CT with delayed imaging

Ureteral injuries should be suspected in complex, multisystem abdominopelvic trauma

Guideline Statement 9b.

Guideline Statement 10a.

Guideline Statement 10b.

J Urol. Author manuscript; available in PMC 2014 August 01.

Guideline Statement 10c.

Guideline Statement 11a.

When an incomplete ureteral injury is at first unrecognized or presents in a delayed fashion,

Guideline Statement 11b.

Surgeons should perform percutaneous nephrostomy with delayed repair as needed in

When the proximal ureter is completely transected or otherwise cannot be cannulated in a

Guideline Statement 12a.

J Urol. Author manuscript; available in PMC 2014 August 01.

Guideline Statement 12b.

Guideline Statement 13a.

periureteral drain. Delayed ureteral reconstruction is often necessary.76,89-91

Guideline Statement 13b.

J Urol. Author manuscript; available in PMC 2014 August 01.

for other associated injuries, patient stability, and ease of testing.

Guideline Statement 14b.

clinical indicators of bladder rupture. (Recommendation; Evidence Strength: Grade C)

J Urol. Author manuscript; available in PMC 2014 August 01.

surgical evaluation of the bladder.

Guideline Statement 15.

Intraperitoneal bladder ruptures must be repaired.19,93,96,98,101,106,109-113 Intraperitoneal

Guideline Statement 16.

Uncomplicated extraperitoneal bladder injuries can be managed using urethral Foley

Guideline Statement 17.

Complicated extraperitoneal bladder ruptures should be surgically repaired in the standard

J Urol. Author manuscript; available in PMC 2014 August 01.